Into the dark. Do you be­lieve your eyes?


Flying - - CONTENTS - By Peter Gar­ri­son

On a No­vem­ber night in 1995, a Beech Baron 58 de­parted from Run­way 24 at Cleve­land’s Burke Lake­front Air­port (KBKL), on the south shore of Lake Erie. It was bound for Raleigh, North Carolina, with five aboard. The Baron climbed to 200 feet above the end of the run­way and be­gan a right turn. The tower con­troller, who had been watch­ing the air­plane, turned away. A cou­ple of min­utes later, he had a call from a city op­er­a­tions of­fice ask­ing whether he could see smoke out on the lake.

The Baron had hit the wa­ter about 6 miles from the air­port. The Coast Guard res­cued two sur­viv­ing pas­sen­gers; the 1,000-hour in­stru­ment-rated pi­lot, 47, and two other pas­sen­gers per­ished. The sur­viv­ing pas­sen­gers re­called no prob­lem with the air­plane or the pi­lot be­fore im­pact.

A Gulf­stream pi­lot who took off shortly af­ter the Baron re­lated to Na­tional Trans­porta­tion Safety Board in­ves­ti­ga­tors that there was no vis­i­ble hori­zon over the lake, and that he would be­come dis­ori­ented if he took his eyes off his in­stru­ments to look out. The NTSB’s re­port faulted the Baron’s pi­lot for his fail­ure to main­tain a pos­i­tive rate of climb af­ter take­off. It made no men­tion of spa­tial dis­ori­en­ta­tion, but did cite the lack of vis­ual ref­er­ences over the wa­ter as a fac­tor.

On a clear, moon­lit evening in Jan­uary 2008, a Baron 58 left KBKL for Ni­a­gara Falls. The pi­lot, 68, an 18,000-hour ATP and CFI–I with a stack of rat­ings, was alone. He took off from Run­way 24 with in­struc­tions to turn right on course. The tower con­troller watched as the Baron climbed, banked to the right and then de­scended in a steep­en­ing arc and plunged into the lake. A fire burned briefly on the wa­ter.

The air­plane and the re­mains of the pi­lot were re­cov­ered. Nei­ther the en­gines them­selves nor the on­board en­gine mon­i­tor gave any in­di­ca­tion of trou­ble; both en­gines were de­vel­op­ing high power un­til the record­ing stopped. The flight con­trol sys­tem ap­peared to have been in­tact up to im­pact.

Although the pi­lot had re­ported us­ing only a choles­terol-reg­u­lat­ing drug with no side ef­fects rel­e­vant to fly­ing, post-mortem tox­i­col­ogy found two painkillers and a heart-dis­ease-re­lated drug in his blood and urine. The pi­lot’s per­sonal med­i­cal records re­vealed that he suf­fered from mild di­a­betes, back pain, hy­per­ten­sion, gas­tric re­flux and var­i­ous car­diac prob­lems. The NTSB did not say that any of these con­di­tions or med­i­ca­tions had any­thing to do with his fly­ing into the lake, but it seemed to sug­gest, by enu­mer­at­ing them, that they could have.

This time, the NTSB did not fault the pi­lot for “im­proper IFR pro­ce­dure,” as it had in the pre­vi­ous ac­ci­dent. In­stead, it said he had be­come spa­tially dis­ori­ented as he


turned out over the dark lake and away from the moon and the lights of Cleve­land. Among the po­si­tional il­lu­sions that oc­cur in the ab­sence of vis­ual ref­er­ences the NTSB cited the “so­matogravic il­lu­sion,” the im­pres­sion of lean­ing back­ward — and there­fore of be­ing in a climb­ing at­ti­tude — that is pro­duced when for­ward ac­cel­er­a­tion presses you against your seat back.

The avail­able ev­i­dence in the two ac­ci­dents was es­sen­tially iden­ti­cal. Shift­ing the blame from the pi­lot’s ac­tions to an ex­ter­nal cause — spa­tial dis­ori­en­ta­tion — might re­flect a cul­tural shift at the NTSB, but changes noth­ing.

In De­cem­ber 2016, an hour be­fore mid­night, a Cessna Ci­ta­tion CJ4 took off from Run­way 24 at KBKL with in­struc­tions to turn right to 330 and main­tain 2,000 feet. You know what hap­pened next.

The pi­lot, in this case, was 45 years old and had 1,200 hours. He had ac­quired his CJ4 sin­gle-pi­lot type rat­ing just three weeks be­fore the ac­ci­dent, but had pre­vi­ously owned a Cessna 510 Mus­tang for two years and logged 370 hours in it. As is cus­tom­ary in sin­gle-pi­lot op­er­a­tions, the pi­lot had been trained to en­gage the au­topi­lot shortly af­ter take­off.

The NTSB’s the­ory of the ac­ci­dent was that the pi­lot be­lieved he had en­gaged the au­topi­lot, but, for what­ever rea­son, it had failed to en­gage. Slight dif­fer­ences be­tween the pan­els of the CJ4 and his pre­vi­ous jet led to “mode con­fu­sion” and the pi­lot’s fail­ing to no­tice that the au­topi­lot an­nun­ci­a­tor in the PFD was not il­lu­mi­nated.

The com­mon thread among these three ac­ci­dents was a take­off in dark­ness fol­lowed by a climb­ing turn to­ward the “black hole” of the lake. Any turn re­quires some back pressure on the yoke; oth­er­wise the nose will drop. In vis­ual con­di­tions, the need to main­tain a climb­ing at­ti­tude is ob­vi­ous to the pi­lot. Lack­ing vis­ual cues, the pi­lot must obey the in­stru­ments. A dis­tracted pi­lot might rely on a phys­i­cal sen­sa­tion of climb­ing that can ex­ist even when the air­plane is de­scend­ing.

In the 1995 ac­ci­dent, the five oc­cu­pants of the Baron had de­layed their de­par­ture an hour in the vain hope of en­coun­ter­ing a pop­u­lar singer who was to be a pas­sen­ger on a Gulf­stream. Per­haps the group was con­vivial; the cock­pit might not have been quite “ster­ile.” The pi­lot ev­i­dently failed to mon­i­tor his in­stru­ments; the air­plane flew into the wa­ter in a suf­fi­ciently shal­low de­scent to al­low two pas­sen­gers to sur­vive.

The 2008 crash was a lit­tle dif­fer­ent. The pi­lot might have been fa­tigued, or drowsy, or af­fected by med­i­ca­tion, or oth­er­wise com­pro­mised, but there is no rea­son to think he was dis­tracted. The NTSB noted in pass­ing that he had failed to re­move the chocks dur­ing his pre­flight, and af­ter start­ing the en­gines “jumped” the chocks to be­gin taxi­ing.

The Ci­ta­tion ac­ci­dent, how­ever, is harder to ex­plain. Un­like the Baron, the jet had an en­hanced ground prox­im­ity warn­ing sys­tem (EGPWS) as well as flight data and cock­pit voice recorders. Apart from an un­re­mark­able er­ror in the pi­lot’s read-back of the de­par­ture con­trol fre­quency, ev­ery­thing on the CVR is nor­mal as the take­off be­gins. The pi­lot re­marks, “That’s when it’s nice to have more thrust than you need.” The sound of move­ment of the land­ing gear han­dle is heard at 22:56:49.3; the jet is soon climb­ing at 6,000 fpm.

The fol­low­ing is the re­main­der of the CVR tran­script. Au­to­mated voices, in­clud­ing alti­tude and EGPWS warn­ings, are in ital­ics.

22:57:09.4 Alti­tude. 22:57:23.4 Alti­tude. 22:57:25.3 Sound of en­gine power de­crease 22:57:27.2 Bank an­gle. Bank an­gle.

22:57:28.6 614SB con­tact de­par­ture. Safe flight. 22:57:30.8 To de­par­ture, 614SB.

At this point, the pi­lot had be­gun to cor­rect his bank an­gle, which had briefly ex­ceeded 60 de­grees, and to re­gain his as­signed alti­tude, which he had over­shot by nearly 900 feet. Ev­i­dently, he was still hand-fly­ing the air­plane.

22:57:37.1 614SB, Lake [front tower, you on] 22:57:39.1 Sink rate. Sink rate. 22:57:39.7 614SB. 22:57:41.4 Sound of in­creas­ing air noise 22:57:43.6 Pull up. 22:57:45.2 Pull up. 22:57:46.2 Sound of over­speed warn­ing be­gins and con­tin­ues till end 22:57:46.8 Pull up. 22:57:48.4 Pull up. 22:57:50.0 Pull up. 22:57:51.6 Pull up. 22:57:53.1 Pull up. 22:57:53.8 Record­ing ends

There was no ev­i­dence of a me­chan­i­cal mal­func­tion or cat­a­strophic event such as a bird strike. The con­di­tion of the re­cov­ered re­mains of the pi­lot pre­cluded an au­topsy or tox­i­col­ogy. The recorded tra­jec­tory of the air­plane was an­a­lyzed by com­puter sim­u­la­tion, with the con­clu­sion that “the flight path was con­sis­tent with the per­for­mance of the air­plane, and no loss of con­trol was ev­i­dent from the data.”

The NTSB’s find­ing of prob­a­ble cause was spa­tial dis­ori­en­ta­tion, to which fa­tigue — the pi­lot had been awake for 17 hours — “mode con­fu­sion” over the sta­tus of the au­topi­lot and “neg­a­tive learn­ing trans­fer” from the fa­mil­iar Mus­tang to the new Ci­ta­tion all con­trib­uted.

Even a sin­gle “pull up” warn­ing should send your eyes straight to the PFD. Ev­i­dently, how­ever, the sub­jec­tive sen­sa­tions of spa­tial dis­ori­en­ta­tion can be so per­sua­sive that for 14 warn­ing-crammed sec­onds an ex­pe­ri­enced jet pi­lot could think his in­stru­ments were ped­dling fake news.

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